Provider Demographics
NPI:1629064126
Name:JOHANSEN, WAYNE A (PT)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:A
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-0031
Mailing Address - Country:US
Mailing Address - Phone:608-356-2334
Mailing Address - Fax:608-356-2636
Practice Address - Street 1:626 14TH ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1535
Practice Address - Country:US
Practice Address - Phone:608-356-2334
Practice Address - Fax:608-356-2636
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1028602OtherPHYSICIANS PLUS INS CORP
WI40414400Medicaid
WIW006005OtherCHAMPUS
WI40119700Medicaid
WI39-1598907-01OtherUNITY HEALTH INSUR
WI0689560001Medicare NSC